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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ��\ 1601 E. HAZELTON AVE., STOCKTUN, CA PERMIT NO. V'3-- /37 o.- Gj, Telephone (209) 466-6781 D�2z 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED ,2. 91-0 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rule an Regulations f the San Joaquin Local Health District. Job Addres JIM1v Subdivision Name Owner's Name Address ',�j-74 S % Phone _ c — Contractor's Name L License No. Phone �( TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ "V PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ G1� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS co U, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Y ['_&mestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑IOther ❑ Delta Type of Casing 2Irrigation Approx. ❑Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other — Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done ,\] Well Destruction LJ Well Diameter Sealing Material (top 50') ~ J Depth Filler Material (Below 50') Insm ASS, (J TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: A_ Number of bedrooms 2 Lot size r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK EX Type/Mfg ( Capacity 0 No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity _ Method of Di s sal SEWAGE SYSTEM Distance to nearest: Well ! Foundation Property Line (}, DESTRUCTION LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wellrt Foundation Property Line V.(� SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: (� FOR ` RTM USE ONLY Application Accepted by Ckoo kn�' . _ Area J=S*S3 ❑ Stk 466-6781 Additional Comments: ��qq11 ❑ L i 369-3621 Pit or Grout Inspection b Date �`''i' Manteca 823-7104 Final Inspection by Date "�� ❑ Tracy 835-6385 Applicant - Return all copi to: nvironmental Health Permit/Services 1601 E. Hazelton A4e` P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 i 10/82 500 14-26